Provider Demographics
NPI:1295730158
Name:PALACIO, PETER EDWARD (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:EDWARD
Last Name:PALACIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 NE MARY ROSE PL
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7132
Mailing Address - Country:US
Mailing Address - Phone:541-385-8050
Mailing Address - Fax:541-385-8589
Practice Address - Street 1:2450 NE MARY ROSE PL
Practice Address - Street 2:SUITE 220
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7132
Practice Address - Country:US
Practice Address - Phone:541-385-8050
Practice Address - Fax:541-385-8589
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-04-10
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OR23150207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287546Medicaid
R112543Medicare ID - Type Unspecified
H42582Medicare UPIN